The aim of this study was to establish current practices amongst general practitioners in the West of Ireland with regard to the investigation, diagnosis and management of urinary tract infection (UTI) in children and to evaluate these practices against recently published guidelines from the National Institute for Health and Clinical Excellence (NICE).
A postal survey was performed using a questionnaire that included short clinical scenarios. All general practices in a single health region were sent a questionnaire, cover letter and SAE. Systematic postal and telephone contact was made with non-responders. The data was analysed using SPSS version 15.
Sixty-nine general practitioners were included in the study and 50 (72%) responded to the questionnaire. All respondents agreed that it is important to consider diagnosis of UTI in all children with unexplained fever. Doctors accurately identified relevant risk factors for UTI in the majority (87%) of cases. In collecting urine samples from a one year old child, 80% of respondents recommended the use of a urine collection bag and the remaining 20% recommended collection of a clean catch sample. Respondents differed greatly in their practice with regard to detailed investigation and specialist referral after a first episode of UTI. Co-amoxiclav was the most frequently used antibiotic for the treatment of cystitis, with most doctors prescribing a five day course.
In general, this study reveals a high level of clinical knowledge amongst doctors treating children with UTI in primary care in the catchment area of County Mayo. However, it also demonstrates wide variation in practice with regard to detailed investigation and specialist referral. The common practice of prescribing long courses of antibiotics when treating lower urinary tract infection is at variance with NICE's recommendation of a three day course of antibiotics for cystitis in children over three months of age when there are no atypical features.
Brain tumours account for <2% of all primary neoplasms but are responsible for 7% of the years of life lost from cancer before age 70 years. The latest survival trends for patients with CNS malignancies have remained largely static. The objective of this study was to evaluate the change in practice as a result of implementing the Improving Outcomes Guidance from the UK National Institute for Health and Clinical Excellence (NICE).
Patients were identified from the local cancer registry and hospital databases. We compared time from diagnosis to treatment, proportion of patients discussed at multidisciplinary team (MDT) meetings, treatment received, length of inpatient stay and survival. Inpatient and imaging costs were also estimated.
Service reconfiguration and implementation of NICE guidance resulted in significantly more patients being discussed by the MDT—increased from 66 to 87%, reduced emergency admission in favour of elective surgery, reduced median hospital stay from 8 to 4.5 days, increased use of post-operative MRI from 17 to 91% facilitating early discharge and treatment planning, and reduced cost of inpatient stay from £2096 in 2006 to £1316 in 2009. Patients treated with optimal surgery followed by radiotherapy with concomitant and adjuvant temozolomide achieved outcomes comparable to those reported in clinical trials: median overall survival 18 months (2-year survival 35%).
Advancing the management of neuro-oncology patients by moving from an emergency-based system of patient referral and management to a more planned elective outpatient-based pattern of care improves patient experience and has the potential to deliver better outcomes and research opportunities.
glioblastoma; management; surgery; radiotherapy; chemotherapy; NICE guidance
Guidelines are a common and important tool in providing high-quality health care. The National Institute for Health and Clinical Excellence (NICE) guidelines are now being used to set standards for assessing the quality of care in UK general practice, and so the evidence behind them needs to be relevant to primary care.
To assess the extent to which guideline recommendations aimed at primary care are based on research conducted in a primary care setting.
Design of study
Purposeful selection of a sample of NICE guidelines for conditions commonly seen in general practice, with identification of the evidence underpinning recommendations that are relevant to primary care.
Three recent NICE guidelines were selected: chronic obstructive pulmonary disease (COPD), hypertension, and respiratory tract infection in adults and children. Publications referenced as evidence for each individual primary care relevant recommendation were classified as to whether or not they were based in primary care relevant settings.
In the three guidelines assessed, 160 studies were used to derive the 115 recommendations that were relevant to, or aimed at primary care. A wide variation was found in the proportion of studies that recruited patients from a setting relevant to primary care (range 26% to 80%).
In this sample of three NICE guidelines, a significant proportion of studies underlying the primary care relevant recommendations were derived from studies that were not conducted in that setting. In producing guidelines for a primary care audience, the guideline development groups should include explicit information about the setting of studies underpinning the recommendations.
evidence-based medicine; practice guidelines; primary care
Background There is evidence that the National Institute for Health and Clinical Excellence (NICE) guidelines for mental health disorders are used to varying degrees in primary care. A lack of access to cognitive–behavioural therapy (CBT) has been found to be a barrier to their implementation. The Improving Access to Psychological Therapies (IAPT) initiative was created in 2007 to increase the availability of NICE-recommended psychological treatments for depression and anxiety disorders within the National Health Service in England.
Aim This study aims to investigate whether general practitioners (GPs) who have access to IAPT services and use NICE guidelines are more likely to use NICE concordant treatments for depression than those who do not. Depression was chosen as it is the most common mental health problem facing primary care physicians.
Method Questionnaires were sent to 830 GPs in southeast England and six GPs were interviewed. The response rate to the questionnaires was 27% (n = 222).
Results Ninety-five per cent of GPs were aware of the NICE guidelines for depression, and 76% had read them. Concordance with the guidelines was significantly higher when GPs had access to a local IAPT service or had read the NICE guidelines.
Conclusions The interviews revealed favourable views to IAPT services when used, although access to treatments was still a common barrier to the implementation of the NICE guidelines for depression.
clinical guidelines; depression; evidence-based treatments
The Quality and Outcomes Framework (QOF) provides an incentive for practices to establish a cancer register and conduct a review with cancer patients within 6 months of diagnosis, but implementation is unknown.
To describe: (1) implementation of the QOF cancer care review; (2) patients' experiences of primary care over the first 3 years following a cancer diagnosis; (3) patients' views on optimal care; and (4) the views of primary care professionals regarding their cancer care.
Design of study
Qualitative study using thematic analysis and a framework approach.
Six general practices in the Thames Valley area.
Semi-structured interviews with cancer patients and focus groups with primary care teams.
Thirty-eight adults with 12 different cancer types were interviewed. Seventy-one primary care team members took part in focus groups. Most cancer care reviews are conducted opportunistically. Thirty-five patients had had a review; only two could recall this. Patients saw acknowledgement of their diagnosis and provision of general support as important and not always adequately provided. An active approach and specific review appointment would legitimise the raising of concerns. Primary care teams considered cancer care to be part of their role. GPs emphasised the importance of being able to respond to individual patients' needs and closer links with secondary care to facilitate a more involved role.
Patients and primary care teams believe primary care has an important role to play in cancer care. Cancer care reviews in their current format are not helpful, with considerable scope for improving practice in this area. An invitation to attend a specific appointment at the end of active treatment may aid transition from secondary care and improve satisfaction with follow-up in primary care.
cancer; primary health care; quality indicators, health care; survivorship
The National Institute for Clinical Excellence (NICE) has produced guidelines on the early management of head injury. This study audits the process of the management of patients with head injury presenting at Accident and Emergency (A&E) departments and examines the impact upon resources of introducing NICE guidelines for eligibility of a CT scan.
A retrospective audit of consecutive patients of any age, presenting at A&E with a complaint of head injury during one month in two northern District General Hospitals forming part of a single NHS Trust.
419 patients presented with a median age of 15.5 years, and 61% were male. 58% had a Glasgow Coma Score (GCS) recorded and 33 (8%) were admitted. Only four of the ten indicators for a CT scan were routinely assessed, but data were complete for only one (age), and largely absent for another (vomiting). Using just three (incomplete) indicators showed a likely 4 fold increase in the need for a CT scan.
The majority of patients who present with a head injury to Accident and Emergency departments are discharged home. Current assessment processes and associated data collection routines do not provide the information necessary to implement NICE guidelines for CT brain scans. The development of such clinical audit systems in a busy A&E department is likely to require considerable investment in technology and/or staff. The resource implications for radiology are likely to be substantial.
Background. Multidisciplinary team (MDT) working in oncology aims to improve outcomes for patients with cancer. One role is to ensure the implementation of best practice and National Institute for Health and Clinical Excellence (NICE) guidance. In this study, we have assessed the role of MDT in implementing the TA121 appraisal of the use of carmustine wafers in high grade gliomas. Methods. 296 patients with high-grade glioma suitable for maximal resection were recruited from 17 Neurosurgical Centres. The number of patients treated with carmustine wafers and reasons for not using this were recorded. Complications at 48 hours post-operatively and at 6 weeks post-radiotherapy were recorded. Results. 94/296 (32%) of suitable patients received carmustine wafers. In 55% of cases carmustine was not used due to either surgeon preference or a lack of an MDT decision. There was no increased complication rate with carmustine use at either 48 hours post-surgery or at 6 weeks post radiotherapy. Use of carmustine wafers did not decrease access to and use of chemoradiotherapy. Conclusions. One third of patients suitable for carmustine wafers received them. Their use was neither associated with more frequent complications, nor decreased use of chemoradiotherapy. Implementation of NICE TA121 Guidance is extremely variable in different MDTs across the United Kingdom.
Brain neoplasms; implementing NICE guidance; carmustine wafers; improving outcomes guidance
Exception reporting allows practices to exclude eligible patients from indicators or an entire clinical domain of the Quality and Outcomes Framework (QOF). It is a source of contention, viewed by some as a ‘gaming’ mechanism.
To explore GP and practice staff views and experiences of exception reporting in the QOF.
Design of study
Qualitative semi-structured interviews.
Interviews with 24 GPs, 20 practice managers, 13 practice nurses, and nine other staff were conducted in 27 general practices in the UK.
Semi-structured interviews, analysed using open explorative thematic coding.
Exception reporting was seen as a clinically necessary part of the QOF. Exempting patients, particularly for discretionary reasons, was seen as an ‘exception to the rule’ that was justified either in terms of practising patient-centred care within a framework of population-based health measures or because of the poor face validity of the indicators. Rates in all practices were described as minimal and the threat of external scrutiny from primary care trusts kept rates low. However, GPs were happy to defend using discretionary exception codes for individual patients. Exception reporting was used, particularly at the end of the payment year, to meet unmet targets and to prevent the practice being penalised financially. Overt gaming was seen as something done by ‘other’ practices. Only two GPs admitted to occasional inappropriate exception reporting.
Exception reporting is seen by most GPs and practice staff as an important and defensible safeguard against inappropriate treatment or over-treatment of patients. However, a minority of practitioners also saw it as a gaming mechanism.
primary care; qualitative research; quality indicators
Since 2006 the Quality Outcomes Framework (QOF) has rewarded GPs for carrying out standardised assessments of the severity of symptoms of depression in newly diagnosed patients.
To gain understanding of GPs' opinions and perceived impact on practice of the routine introduction of standardised questionnaire measures of severity of depression through the UK general practice contract QOF.
Design of study
Semi-structured qualitative interview study, with purposive sampling and constant comparative analysis.
Thirty-four GPs from among 38 study general practices in three sites in England, UK: Southampton, Liverpool, and Norfolk.
GPs were interviewed at a time convenient to them by trained interviewers. Interviews were audiorecorded and transcribed verbatim in preparation for thematic analysis, to identify key views.
Analysis of the interviews suggested that the use of severity questionnaires posed an intrusion into the consultation. GPs discursively polarised two technologies: formal assessment versus personal enquiry, emphasising the need to ensure the scores are used sensitively and as an aid to clinical judgement rather than as a substitute. Importantly, these challenges implicitly served a function of preserving GPs' identities as professionals with expertise, constructed as integral to the process of diagnosis.
GP accounts indicated concern about threats to patient care. Contention between using severity questionnaires and delivering individualised patient care is significantly motivated by GP concerns to preserve professional expertise and identity. It is important to learn from GP concerns to help establish how best to optimise the use of severity questionnaires in depression.
depression; diagnosis; general practice
This paper, while reviewing the legal authority held by clinical guidelines, examines the NICE head injury guidelines with respect to the likely consequences of non-compliance. Conversely, the effect on medical practice of rigid adherence to guidelines is also explored. Debate about the appropriateness of NICE head injury guidelines has highlighted the extent to which existing practices will need to change if compliance is to be achieved. Although a degree of resistance remains, there is perhaps a sense of resignation that the management of patients with head injuries will follow nationally prescribed guidance, whether in its current form or following its review next June. There will undoubtedly be those who remain unconvinced of the validity of these guidelines. Despite this, a possible reason for compliance may arise from concerns about the consequences of non-conformity. With the aid of a fictional scenario, this article seeks to remind the reader of the legal authority held by guidelines, the likely consequences of non-compliance and the liability held by their authors should compliance result in an untoward outcome. Finally, consideration is given to the possible long term effects that the adoption of guidelines may have on the medical profession.
Mortality from coronary heart disease has been falling in the UK since the 1970s, but remains higher than in most other Western countries. Most patients receive some treatment for secondary prevention after myocardial infarction, but not all patients are offered the most effective secondary prevention package. The recently published NICE guideline for secondary prevention in patients after myocardial infarction, summarised in this article, makes clear recommendations for management of patients after myocardial infarction, based on best available evidence. The guidelines update the 2001 NICE guideline, and have expanded and emphasised the recommendations for physical activity, dietary and other lifestyle changes, and cardiac rehabilitation, and updated the recommendations for drug therapy.
Background: NICE guidelines for the management of head injury were published in June 2003. Their recommendations differ markedly from previous guidelines published by the Royal College of Surgeons (RCS). In place of skull radiography and admission, computed tomography (CT) is advocated. The impact of these guidelines on service provision in the UK is unknown.
Methods: Data on all clinical correlates of children presenting with any severity of head injury was collected in three hospitals in the northwest of England. The current skull radiograph (SXR), CT scan, and admission rates were determined. The rates of SXR, CT scan, and admission that should have occurred when following either the RCS or NICE guidelines were then determined.
Results: Data from 10 965 patients who attended three hospitals between February 2000 and August 2002 was studied. Twenty five per cent of patients received a SXR, 0.9% a CT scan, and 3.7% were admitted. Strict adherence to the RCS guidelines would have resulted in a 50% SXR rate, a 1.6% CT scan rate, and a 7.1% admission rate. Adherence to NICE guidelines would result in a 0.3% SXR rate, an 8.7% CT scan rate, and a 1.4% admission rate, although the CT rate would drop to 6.3% if vomiting three or more times in the under 12s was used instead of more than one vomit.
Conclusions: The new NICE guidelines do not increase the workload caused by patients attending with head injury but they move their management from the observation ward to the radiology department.
Background: The NICE head injury guidelines recommend a different approach in the management of head injury patients. It suggests that CT head scan should replace skull x ray (SXR) and observation/admission as the first investigation. We wished to determine the impact of NICE on SXR, CT scan, and admission on all patients with head injury presenting to the ED setting and estimate the cost effectiveness of these guidelines, which has not been quantified to date.
Design: Study of head injury patients presenting to two EDs before and after implementation of NICE guidelines
Methods: The rate of SXR, CT scan, and admission were determined six months before and one month after NICE implementation in both centres. The before study also looked at predicted rates had NICE been applied. This enabled predicted and actual cost effectiveness to be determined.
Result: 1130 patients with head injury were studied in four 1 month periods (two in each centre). At the teaching hospital, the CT head scan rate more than doubled (3% to 7%), the SXR declined (37% to 4%), while the admission rate more than halved (9% to 4%). This represented a saving of £3381 per 100 head injury patients: greater than predicted with no adverse events. At the District General Hospital, the CT head scan rate more than quadrupled (1.4% to 9%), the SXR dropped (19 to 0.57%), while the admission rate declined (7% to 5%). This represented a saving of £290 per 100 head injury patients: less than predicted.
Conclusion: The implementation of the NICE guidelines led to a two to fivefold increase in the CT head scan rate depending on the cases and baseline departmental practice. However, the reduction in SXR and admission appears to more than offset these costs without compromising patient outcomes.
To answer concerns related to implementation of the National Institute for Clinical Excellence (NICE) guideline on the management of head injury by determining the impact on the workload of a district general hospital. Increased computed tomography (CT) was of particular concern (cost, radiation risk, and delivery constraints).
Retrospective audit of all patients attending the hospital's emergency department with a head injury over a three month period. Any reattendees for the same head injury episode were excluded but the need for CT was recorded. Case notes and electronic records were reviewed to determine whether the CT head or skull radiograph (SXR) was indicated in line with the NICE guideline. The workload was compared with an identical audit performed before the implementation of the NICE guideline.
Of 17 472 patients attending the ED in 2004, 472 had a head injury. CT scan was indicated in 36, a significant increase from 2003 (p<0.001). No SXR was indicated but two were performed, a significant decrease (p<0.001). The admission rate was unaltered. The positive predictive value of NICE was 17.1% compared with 25% (p = not significant) for the authors' pre‐NICE departmental guideline.
This department has seen an increase in CT head requests since the implementation of the NICE guideline. This costs an extra £15 000 per 100 head injuries annually for this department, with an estimated £51.7 million burden for England and Wales. Further evaluation is required as there were only nine brain injuries in this audit population.
NICE head injury guideline; CT scan; skull radiograph; workload; cost benefit
Rising demand and increasing waiting times for upper gastrointestinal endoscopy (gastroscopy).
Quality improvement study with pre‐ and post‐intervention data collection.
Three endoscopy units in two hospital trusts (Singleton, Morriston and Baglan Hospitals endoscopy units), UK.
Key measures for improvement
Number of gastroscopy requests from general practitioners (GPs) and hospital doctors; their adherence to dyspepsia referral guidelines and the referral‐to‐procedure interval for upper gastroscopy. Data collected for six months before and for five months after the intervention.
Strategy for change
Referrals were assessed against the National Institute for Health and Clinical Excellence (NICE) guidelines for the management of dyspepsia by two part‐time GPs and feedback sent to clinicians where requests did not adhere to the referrals criteria
Effects of change
Adherence to guideline criteria increased significantly among GPs after the intervention (from 55% to 75%). There was no similar effect for hospital doctors, although their adherence rate (70%) was at a higher level than that of GPs before the intervention. The number of gastroscopy referrals for dyspepsia declined after the intervention, particularly from hospital doctors where a drop of 31% was observed, from 26.6 to 18.4 referrals per week. With the inclusion of seasonal effects, an estimated drop of 3.2 referrals per week from general practice was not significant (p = 0.065) while an estimated drop of 10.0 referrals per week for hospital doctors was very significant (p<0.001).
Referral assessment can be successfully introduced and shows promise as a way of improving the quality of referrals and reducing demand. Hospital clinicians are more resistant than GPs to referral assessment but nevertheless responded to the feedback by reducing their endoscopy gastroscopy requests. Most such referrals are generated in hospitals rather than in primary care: this finding has important implications for demand management.
To compare recent U.S. and U.K. guidelines on gestational diabetes mellitus (GDM).
RESEARCH DESIGN AND METHODS
The guidelines from the American Diabetes Association, the American College of Obstetricians and Gynecologists, and the National Institute for Health and Clinical Excellence (NICE) in the U.K. were collated and compared using a general inductive approach.
There are substantial differences in the recommendations between the U.K. and the U.S. guidelines. Of particular note are the reduced sensitivities of the early and later antenatal and postnatal screening and diagnostic criteria. NICE undertook a cost-effectiveness analysis using lower prevalence estimates and limited outcomes and still showed screening for GDM to be cost-effective.
The latest NICE recommendations appear to reduce access to proven, cost-effective management of GDM, an issue relevant in the current U.S. health care policy debate.
Most patients contact their general practitioner (GP) following presentation to an Emergency Department (ED) after a self-harm incident, and strategies to help GPs manage these patients include efficient communication between services. The aim of this study was to assess the standard of documentation and communication to primary care from secondary care as recommended by the National Institute of Clinical Excellence (NICE) guidelines on the short-term management of people who self-harm.
An audit of medical records (ED and Psychiatric) on people aged 16 years and over who had presented to the ED following self-harm, benchmarked according to government guidelines, was performed. Data were collected over a 4-week period at a general teaching hospital.
We collected data on 93 consecutive episodes of self-harm; 62% of episodes were communicated to primary care, 58% of these communications were within 24 h and most within 3 days. Patient identifying details and follow-up arrangements were specified in most cases. Communication via psychiatric staff was most detailed. ED clinicians provided few communications and were of limited content. Communication with the patient's GP was not made in half of those cases seen by a mental health specialist.
Government guidelines are only partially being met. Reliance on communication by ED staff would leave a substantial proportion of patients discharged from the ED with no or minimal communication to primary care. Psychiatric services need to improve the rate of communication to the patient's GP following assessment A national sample of National Health Service (NHS) trusts would establish if this is a problem elsewhere.
The goal of antiepileptic treatment is to achieve seizure freedom or seizure control. The aim of this paper is to review the evidence for the use of lacosamide for adjunctive treatment of refractory focal seizures with or without secondary generalization, within the scope of the 2012 update of the Clinical Guideline published by the National Institute for Health and Clinical Excellence (NICE).
Clinical evidence for the use of lacosamide and other antiepileptic drugs (AEDs) was systematically reviewed, evaluated, and presented to the Guideline Development Group. Only randomized clinical trials were included. Outcomes of clinical efficacy (seizure freedom, 50% reduction in seizure frequency, time to first seizure, time to 12-month remission, treatment withdrawal, and time to treatment withdrawal), experience of adverse events, and cognitive and quality of life outcomes were reviewed. A decision model was built to weigh the clinical benefits of each adjunctive AED, measured by seizure control and seizure reduction, compared with the harm from adverse events, as measured by withdrawals from treatment due to adverse events.
Lacosamide was included as part of the recommended AEDS to be used in tertiary epilepsy centers. The evidence review showed that more participants who received lacosamide as an adjunctive treatment had at least a 50% reduction in seizure frequency compared with those taking placebo. However, more participants on lacosamide were found to experience adverse events and withdrawal from treatment compared with those on placebo. The cost-effectiveness analysis showed that compared with placebo, the benefits gained from adjunctive lacosamide were modest and uncertain, whereas the costs were significantly high. Compared with other AEDs licensed for adjunctive therapy in focal seizures, lacosamide was associated with fewer quality-adjusted life years and higher costs. Therefore, the Guideline Development Group noted that the balance of benefit and harm needs to be carefully monitored in all patients.
focal seizures; anti-epileptic drug; adjunctive therapy; clinical guideline
The National Institute for Health and Clinical Excellence (NICE) has recently released obesity guidelines for health risk. For the first time in the UK, we estimate the utility of these guidelines by relating them to the established cardiovascular disease (CVD) risk factors. Health Survey for England (HSE) 2006, a population-based cross-sectional study in England was used with a sample size of 7225 men and women aged ≥35 years (age range: 35–97 years). The following CVD risk factor outcomes were used: hypertension, diabetes, total and high density lipoprotein cholesterol, glycated haemoglobin, fibrinogen, C-reactive protein and Framingham risk score. Four NICE categories of obesity were created based on body mass index (BMI) and waist circumference (WC): no risk (up to normal BMI and low/high WC); increased risk (normal BMI & very high WC, or obese & low WC); high risk (overweight & very high WC, or obese & high WC); and very high risk (obese I & very high WC or obese II/III with any levels of WC. Men and women in the very high risk category had the highest odds ratios (OR) of having unfavourable CVD risk factors compared to those in the no risk category. For example, the OR of having hypertension for those in the very high risk category of the NICE obesity groupings was 2.57 (95% confidence interval 2.06 to 3.21) in men, and 2.15 (1.75 to 2.64) in women. Moreover, a dose-response association between the adiposity groups and most of the CVD risk factors was observed except total cholesterol in men and low HDL in women. Similar results were apparent when the Framingham risk score was the outcome of interest. In conclusion, the current NICE definitions of obesity show utility for a range of CVD risk factors and CVD risk in both men and women.
National Institute for Health and Clinical Excellence (NICE) clinical guidelines and subsequent NICE issued ‘recommendation reminders’ advocate discontinuing two fertility procedures and caesarean sections in women with hepatitis. We assess whether NICE guidance in 2004 and recommendation reminders were associated with a change in the rate of clinical procedures performed.
Routine inpatient Hospital Episode Statistics (HES) data were extracted from the HES database for 1st April 1998 to 31st March 2010 using OPCS procedure codes for varicocele operations in infertile men, endometrial biopsies in infertile women and caesarean sections in women with hepatitis B or C. We used Joinpoint regression to identify points in time when the trend in procedure rates changed markedly, to identify any influence of the release of NICE guidance.
Between 1998-2010, planned caesarean sections in women with and without hepatitis B or C increased yearly (annual percentage change (APC) 4.9%, 95% CI 2.1% to 7.7%) in women with hepatitis, compared with women without (APC 4.0% [95% CI 2.7% to 5.3%] up to 2001, APC -0.6% [95% CI -2.8% to 1.8%] up to 2004 and 1.3% [95% CI 0.8% to 1.8%] up to 2010). In infertile women under 40 years of age, endometrial biopsies for investigation of infertility increased, APC 6.0% (95% CI 3.6% to 8.4%) up to 2003, APC 1.5% (95% CI -4.3% to 7.7%) to 2007 followed by APC 12.8% (95% CI 1.0% to 26.0%) to 2010. Varicocele procedures remained relatively static between 1998 and 2010 (APC -0.5%, 95% CI -2.3% to 1.3%).
There was no decline in use of the three studied procedures, contrary to NICE guidance, and no change in uptake associated with the timing of NICE guidance or recommendation reminders. ‘Do not do’ recommendation reminders may be ineffective at improving clinical practice or achieving disinvestment.
NICE; Clinical guidelines; Fertility; Caesarean
Venous thromboembolism (VTE) is a major cause of morbidity and mortality in hospitalised patients. VTE prevention has been identified as a major health need internationally to improve patient safety. A National Institute for Health and Clinical Excellence (NICE) guideline was issued in February 2010. Its key priorities were to assess patients for risk of VTE on admission to hospital, assess patients for bleeding risk and evaluate the risks and benefits of prescribing VTE prophylaxis.
The aim of this study was to evaluate the implementation of NICE guidance and its impact on patient safety.
A before-after observational design was used to investigate changes in VTE risk assessment documentation and inappropriate prescribing of prophylaxis between the year prior to (2009) and the year following (2010) the implementation of NICE guidance, using data from a 3-week period during each year. A total of 408 patients were sampled in each year across four hospitals in the NHS South region.
Implementation strategies such as audit, education and training were used. The percentage of patients for whom a VTE risk assessment was documented increased from 51.5% (210/408) in 2009 to 79.2% (323/408) in 2010; difference 27.7% (95% CI: 21.4% to 33.9%; p < 0.001). There was little evidence of change in the percentage who were prescribed prophylaxis amongst patients without a risk assessment (71.7% (142/198) in 2009 and 68.2% (58/85) in 2010; difference −3.5% (95% CI: -15.2% to 8.2%; p =0.56) nor the percentage who were prescribed low molecular weight heparin amongst patients with a contraindication (14% (4/28) in 2009 and 15% (6/41) in 2010; RD = 0.3% (95% CI: -16.5% to 17.2%; p =0.97).
The documentation of risk assessment improved following the implementation of NICE guidance; it is questionable, however, whether this led to improved patient safety with respect to prescribing appropriate prophylaxis.
Venous thromboembolism (VTE); Implementation strategies; NICE; Patient safety
Objective To quantify the change in prescribing of antibiotic prophylaxis before invasive dental procedures for patients at risk of infective endocarditis, and any concurrent change in the incidence of infective endocarditis, following introduction of a clinical guideline from the National Institute for Health and Clinical Excellence (NICE) in March 2008 recommending the cessation of antibiotic prophylaxis in the United Kingdom.
Design Before and after study.
Population All patients admitted to hospital in England with a primary or secondary discharge diagnosis of acute or subacute infective endocarditis.
Main outcome measures Monthly number of prescriptions for antibiotic prophylaxis consisting of a single 3 g oral dose of amoxicillin or a single 600 mg oral dose of clindamycin, and monthly number of cases of infective endocarditis, infective endocarditis related deaths in hospital, or cases of infective endocarditis with a possible oral origin for streptococci.
Results After the introduction of the NICE guideline there was a highly significant 78.6% reduction (P<0.001) in prescribing of antibiotic prophylaxis, from a mean 10 277 (SD 1068) prescriptions per month to 2292 (SD 176). Evidence that the general upward trend in cases of infective endocarditis before the guideline was significantly altered after the guideline was lacking (P=0.61). Using a non-inferiority test, an increase in the number of cases of 9.3% or more could be excluded after the introduction of the guideline. Similarly an increase in infective endocarditis related deaths in hospital of 12.3% or more could also be excluded.
Conclusion Despite a 78.6% reduction in prescribing of antibiotic prophylaxis after the introduction of the NICE guideline, this study excluded any large increase in the incidence of cases of or deaths from infective endocarditis in the two years after the guideline. Although this lends support to the guideline, ongoing data monitoring is needed to confirm this, and further clinical trials should determine if antibiotic prophylaxis still has a role in protecting some patients at particularly high risk.
The new GMS contract has led to practice nurses playing an important role in the delivery of the Quality and Outcomes Framework (QOF).
This study investigated how practice nurses perceive the changes in their work since the contract's inception.
Design of study
A qualitative approach, sampling practice nurses from practices in areas of high and low deprivation, with a range of QOF scores.
Individual interviews were conducted, audiotaped, transcribed, and analysed using a thematic approach.
Three themes emerged: roles and incentives, workload, and patient care. Practice nurses were positive about the development of their professional role since the introduction of the new GMS contract but had mixed views about whether their status had changed. Views on incentives (largely related to financial rewards) also varied, but most felt under-rewarded, irrespective of practice QOF achievement. All reported a substantial increase in workload, related to incentivised QOF domains with greater ‘box ticking’ and data entry, and less time to spend with patients. Although the structure created by the new contract was generally welcomed, many were unconvinced that it improved patient care and felt other important areas of care were neglected. Concern was also expressed about a negative effect of the QOF on holistic care, including ethical concerns and detrimental effects on the patient–nurse relationship, which were regarded as a core value.
The new GMS contract has given practice nurses increased responsibility. However, discontent about how financial gains are distributed and negative impacts on core values may lead to detrimental long-term effects on motivation and morale.
GMS contract; incentives; practice nurses; primary health care
Hyperglycemia is associated with increased mortality in critically ill patients. Randomized trials of intensive insulin therapy have reported inconsistent effects on mortality and increased rates of severe hypoglycemia. We conducted a meta-analysis to update the totality of evidence regarding the influence of intensive insulin therapy compared with conventional insulin therapy on mortality and severe hypoglycemia in the intensive care unit (ICU).
We conducted searches of electronic databases, abstracts from scientific conferences and bibliographies of relevant articles. We included published randomized controlled trials conducted in the ICU that directly compared intensive insulin therapy with conventional glucose management and that documented mortality. We included in our meta-analysis the data from the recent NICE-SUGAR (Normoglycemia in Intensive Care Evaluation — Survival Using Glucose Algorithm Regulation) study.
We included 26 trials involving a total of 13 567 patients in our meta-analysis. Among the 26 trials that reported mortality, the pooled relative risk (RR) of death with intensive insulin therapy compared with conventional therapy was 0.93 (95% confidence interval [CI] 0.83–1.04). Among the 14 trials that reported hypoglycemia, the pooled RR with intensive insulin therapy was 6.0 (95% CI 4.5–8.0). The ICU setting was a contributing factor, with patients in surgical ICUs appearing to benefit from intensive insulin therapy (RR 0.63, 95% CI 0.44–0.91); patients in the other ICU settings did not (medical ICU: RR 1.0, 95% CI 0.78–1.28; mixed ICU: RR 0.99, 95% CI 0.86–1.12). The different targets of intensive insulin therapy (glucose level ≤ 6.1 mmol/L v. ≤ 8.3 mmol/L) did not influence either mortality or risk of hypoglycemia.
Intensive insulin therapy significantly increased the risk of hypoglycemia and conferred no overall mortality benefit among critically ill patients. However, this therapy may be beneficial to patients admitted to a surgical ICU.
The care and provision for children and adults with epilepsy and their carers has recently been under scrutiny with a series of reports highlighting concerns and calling for change. The National Institute for Clinical Excellence (NICE) published recommendations for management of adults and children in October 2004. Although recommendations were often specific and practical they did not include precise details regarding their implementation. Key recommendations and their implications are discussed in this review.
epilepsy; NICE; epilepsy services